An Introduction to Irrigation

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An Introduction to Irrigation

Colostomy Irrigation can, in suitable cases, be an alternative to wearing a stoma pouch. Irrigation is used to manage faecal output by cleansing the bowel. It involves using specialist equipment to introduce a measured amount of water into the bowel via the stoma. The water then causes muscular contractions within the bowel, which in turn cause expulsion of its contents. Irrigation does not wash out the entire bowel but clears the lower (distal) colon of faeces. This enables the bowel to perform the function normally performed by the rectum of storing faeces until it is evacuated.

Managing a colostomy The most common way in the United Kingdom of managing a colostomy is through natural action and the wearing of a pouch. There is no control over the bowel and the pouch usually has to be changed twice per day. Many colostomates find that certain foods can cause problems with wind, loose stools and odour. Laxatives may be required to regulate motions and some colostomates never develop a regular evacuation pattern. This can lead to a demoralising change in many aspects of a person’s life.

Freedom and control In general, irrigation is a safe and effective method for achieving a continent bowel. It needs to be discussed with, and taught by, a stoma care nurse, and the correct procedure must be followed. It is not a technique which suits everybody, although for colostomates who suffer persistent problems with their colostomy it may be an appropriate option. Irrigation can give the colostomate a new sense of freedom and control.

Irrigation The aim of irrigation is for faeces to be passed only when the bowel is irrigated. There is then no need for a colostomy pouch to be worn: the stoma is covered by a discreet cap. Colostomy irrigation is a well established procedure that can be used by patients at home to achieve control over their bowel function, and can improve their confidence and quality of life.

Advantages of Irrigation: • Control is achieved over bowel function. Irrigation is performed at a time chosen by the person, and between irrigations they are continent. • A small appliance (stoma cap) is all that is needed to cover the stoma. This can minimise the anxiety caused by altered body image and give more confidence with appearance. Those who irrigate are at no disadvantage when participating in active sports, subject to there being no abdominal weakness. • Typically, a more varied diet can be enjoyed and the worry of wind, irregular motions and constipation is likely to be minimal. • Disposal of used colostomy pouches is eliminated. • Irrigation can prevent or reduce problems associated with pouch leakage and allergies. • There are fewer supplies to store or carry around - typically one stoma cap will be used each day instead of two pouches each day.

And the disadvantages: • Irrigation is time-consuming and may need to be performed every day, although if 48 hours’ continence is not achieved it might be argued that the benefit is not worth the effort. • The toilet or bathroom will be required for 45 - 60 minutes. • It should preferably be performed as a regular routine, and continued even if the colostomate is on holiday or away with work. • Some people may view it as an unnatural procedure and distasteful to perform.

An Introduction to Irrigation

Who can Irrigate? • Those with an end colostomy situated in the lower part of the large bowel. • Motions should normally be semi-formed or formed. • Reasonable eyesight and dexterity are required to be able to manage the procedure successfully. • Colostomates will need to make an informed choice about undertaking this procedure and be motivated and keen to succeed. • The surgeon’s consent must be obtained prior to commencing irrigation, since with some medical conditions irrigation is inadvisable. It is also desirable to mention to the GP that irrigation is intended.

Who cannot Irrigate? • People with complications such as a prolapse, stenosis or large hernia. • Those with further bowel disease e.g. Crohn’s disease or diverticulitis. • Irrigation may not be successful for those suffering from persistent diarrhoea. • Patients receiving radiotherapy or chemotherapy. • Young children who have difficulty sitting still for the required time. As with all teaching of young children, if the child is old enough to take an interest in the working of the stoma, it may be possible to overcome this difficulty by making a game of it: “Let’s see how long you can go without needing a bag”. • People with renal or cardiac problems. Irrigation could cause fluid overload, or slow the heart rate excessively by stimulating the vagus nerve.

When can irrigation start? Irrigation can be taught post-operatively when the bowel has started to function. However, many people have more than enough to cope with, in coming to terms with major surgery, and most stoma care nurses prefer to wait two or three months so that the patient has had a period of recovery and adjustment. A useful guide is when normal appetite has returned. It is helpful for the stoma care nurse to give a full explanation prior to guiding the patient through the procedure. Booklets, videos and DVDs are available. It can also be helpful before making a decision to talk to another person who irrigates.

How is irrigation taught? Ideally this procedure should be taught at home. The stoma care nurse should visit the patient to determine whether any adjustments need to be made. Usually all that is required is a hook above the toilet, on which the water reservoir can be hung. The stoma care nurse will explain the equipment, and assist the patient through the irrigation. Additional visits for the first few irrigations can be useful to ensure that the patient is irrigating safely and using the equipment correctly, and to answer any questions which may arise. Irrigation needs to be performed when the toilet or bathroom is free for an hour. Having to rush can lead to anxiety and is likely to cause the procedure to fail. Irrigation should as far as possible always be performed at the same time of day.

An Introduction to Irrigation

Equipment and supplies required: Irrigation equipment is available on prescription from various manufacturers. The equipment always has the same basic components:

1 Water reservoir 2 Tubing with flow control 3 A cone: a nozzle with a smooth rounded tip to make it easy to insert into the stoma, and which is flared out to enable it to make a seal round the stoma 4 Lubricating jelly to aid the insertion of the cone 5 Irrigation belt and flange (not normally required for colostomates using two-piece appliances)

Water reservoir, tubing, flow control and cone

6 Disposable irrigation sleeve 7 Disposal bag 8 Tissues or toilet paper 9 New appliance to be worn, and any accessories used Irrigation belt flange and sleeve

The water container should be clear, enabling the water level to be seen, and should desirably have a liquid crystal temperature indicator. The flow control should be easy to operate with one hand. The irrigation flange should give a secure seal around the stoma and the sleeve should be long enough to hang into the toilet. It can be trimmed if needed. Once used, the flange and cone should be washed with warm soapy water, dried and stored until their next use. There is normally no need to wash the reservoir.

How to irrigate: 1 Connect the reservoir, tubing and cone together. Fill the reservoir with tepid (37-38°C) tap water and hang it on a hook, such that the bottom of the reservoir is at shoulder level or slightly above when the colostomate is in the position adopted for irrigation. A stool somewhat higher than the WC will often be found to provide the most comfortable position. 2 Open the flow control to allow water through the tubing to expel air, and then close the control when the desired amount of water remains in the reservoir. 3 Fit the irrigation sleeve over the stoma and sit on the toilet, or on a stool adjacent to it, so that the sleeve hangs into the bowl. 4 Lubricate the cone and insert it gently into the stoma following the direction of the bowel. The stoma care nurse will help with this at first. 5 Open the flow control on the reservoir and allow the water to run slowly into the bowel slowly. This should take 8-15 minutes. Most people use 800ml to 1.2 litres but the optimum amount may vary from 700ml to about 1.6 litres. Patients get to know by experience what quantity works best for them. Should cramping or pain be experienced during this time close the flow control, massage the abdomen and wait a few minutes before restarting. For the first irrigations patients may wish to restrict the rate of flow, but with experience they usually find that they can let the colon determine the rate. 6 When the water has run in, remove the cone from the stoma and close the top of the sleeve. 7 Water and stools will begin to flow into the irrigation sleeve. It can take up to 30 minutes to complete the evacuation. An opportunity to catch up with some reading! 8 Wait about five minutes after everything appears to have been expelled, then remove the sleeve, wash and dry around the stoma and apply the usual stoma cap or appliance. 9 Dispose of the sleeve in the usual way, wash and dry the equipment used and store until next time.

How to contact us...

2 London Court East Street Reading RG1 4QL Tel: 0118 939 1537 Helpline: 0800 328 4257 E-mail: [email protected] Website: www.colostomyassociation.org.uk

We would like to take this opportunity to thank Stoma Care Nurses, Andrea Thomas RGN ENB and Clare Bossom EN RGN 216 and Adrian March - Colostomy Association Trustee for their kind assistance in the production of this booklet